Introduction

The increasing global prevalence of obesity and diet-related diseases has brought into sharp focus the need to manage our consumption of free sugars. Non-sugar sweeteners (NSS), often promoted as aids for weight loss and substitutes for sugar for those with diabetes, have been seen as a potential solution. However, the long-term health effects and overall effectiveness of NSS remain enigmatic. In response to this, the World Health Organization (WHO) has diligently published guidelines on the utilization of NSS to encourage healthier diets and avert diet-related diseases.

Deciphering the Evidence

Recent studies offer a mixed bag of results. Evidence suggests that short-term usage of NSS in adults can lead to a lower body weight and Body Mass Index (BMI). However, the long-term use of NSS tells a different story - an increased BMI and a heightened risk of obesity. More alarmingly, long-term NSS consumption may also increase the risk of type 2 diabetes, cardiovascular diseases, and overall mortality. Short-term studies, on the other hand, did not observe significant impacts on disease markers such as fasting glucose or blood lipids.

The picture becomes even more complex when considering children and pregnant women. Some studies suggest that NSS can reduce body fatness in children and dental caries with stevia use. However, no significant associations were found with other health outcomes. Meanwhile, observational studies report an increased risk of preterm birth and potential risk of asthma, allergies, and poorer cognitive function in offspring with high NSS use during pregnancy. Further research is necessary to clarify these findings.

The WHO's Stance on Non-Sugar Sweeteners

The WHO, drawing from systematic reviews characterized by uncertain evidence, advises against the use of NSS for weight control or reducing the risk of noncommunicable diseases. These reviews found no long-term benefits on body fatness from NSS use, but potential harmful effects such as an increased risk of type 2 diabetes, cardiovascular diseases, and mortality in adults, as well as potential risk of preterm birth during pregnancy.

In short-term randomized controlled trials, NSS led to reduced sugars and energy intake, resulting in lower body weight and BMI. However, these effects were not replicated in longer-term trials. Prospective observational studies associated higher NSS intake with higher BMI and increased risk of obesity, type 2 diabetes, and mortality.

For children, one trial found that replacing sugar-sweetened drinks with NSS-containing ones reduced body fatness, but no significant associations were found between NSS use and health outcomes. Pregnant women with higher NSS use during pregnancy might face an increased risk of preterm birth, and their offspring may potentially experience increased risk of asthma and poorer cognitive function.

Types of Non-Sugar Sweeteners

Non-sugar sweeteners (NSS) can be classified into two main types: synthetic and natural.

Synthetic sweeteners include acesulfame K, aspartame, advantame, cyclamates, neotame, saccharin, and sucralose. They are often found in 'diet' or 'zero-calorie' beverages, sugar-free gums, candies, dairy products, baked goods, and are also sold as tabletop sweeteners.

Natural NSS include stevia, a plant-based sweetener. It's commonly found in health foods, diet drinks, cereals, and sugar-free or reduced-sugar snacks.

It's important to note that low-calorie sugars and sugar alcohols, which contain calories, are not considered NSS. They are found in a range of food and beverages and are often used in sugar-free and 'diet' products.

1. Acesulfame K:

• Soft drinks and fruit juices
• Tabletop sweeteners
• Dairy products
• Ice cream
• Desserts
• Jams and jellies

2. Aspartame:

• Diet soft drinks
• Sugar-free chewing gum
• Low-calorie fruit juices
• Cereals
• Sugar-free or "diet" candies
• Flavored water beverages
• Some multivitamins and pharmaceuticals

3. Advantame:

• Chewing gum
• Candies
• Frostings
• Non-alcoholic beverages
• Jams and jellies
• Processed fruits and fruit juices
• Toppings and syrups

4. Cyclamates:‍

Cyclamates are banned in the U.S. due to health concerns but are still used in some countries.

• Tabletop sweeteners
• Soft drinks
• Desserts

5. Neotame:

• Soft drinks
• Chewing gum
• Dairy products
• Frozen desserts
• Baked goods

6. Saccharin:

• Diet soft drinks
• Tabletop sweeteners
• Processed foods
• Baked goods
• Jams, jellies, and fruit canned in syrup

7. Sucralose:

• Soft drinks
• Baking mixes
• Breakfast cereals
• Snack foods
• Frozen desserts
• Tabletop sweeteners

8. Stevia:

• Diet soft drinks and teas
• Dairy products like yogurt
• Baked goods
• Candy
• Tabletop sweeteners
• Jams and sauces

Remember, the content of these sweeteners in the mentioned foods may vary between brands and product lines. It's always best to check the nutrition facts label if you're trying to avoid or limit these sweeteners. List of high intensity sweeteners approved by the US FDA can be found here.

Navigating Uncertain Waters

Given the lack of certainty about the overall balance of potential benefits and risks associated with long-term NSS use, the recommendation from the WHO took a conservative approach. NSS are not essential dietary factors and have no nutritional value. Reducing free sugar intake can also be achieved through other methods such as consuming fruit and unsweetened foods and beverages.

This recommendation against non-sugar sweeteners for weight control or reducing noncommunicable disease risk applies to everyone, excluding individuals with diabetes. The recommendation covers all types of NSS, both synthetic and natural, including acesulfame K, aspartame, advantame, cyclamates, neotame, saccharin, sucralose, and stevia. However, it does not apply to low-calorie sugars and sugar alcohols, which contain calories and are not considered NSS.

Conclusion

The guideline's recommendation is underpinned by the potential health effects of NSS as a class of compounds, despite their differing chemical structures and physiological effects. The objective is clear – reduce free sugars intake.